Aims. Revision hip arthroplasty for femoral stem loosening remains challenging due to significant bone loss and deformities requiring specialized revision stems. The aim of this study was to evaluate the clinical and radiological outcomes, and survival, of a consecutive series of femoral revisions performed using a primary cementless stem with tapered geometry and rectangular cross-section at medium-term follow-up. Methods. We retrospectively evaluated 113 patients (115 hips) with intraoperative Paprosky type I (n = 86) or II (n = 29) defects, who underwent femoral revision with Alloclassic Zweymüller SL stem for one-stage aseptic revision or two-stage septic revision from January 2011 to December 2020. The mean follow-up was 77.9 months (SD 33.8). Nine patients were lost to follow-up (deceased or not available), leaving 104 patients (106 hips) for the clinical and radiological analysis. Clinical assessment was performed with Harris Hip Score (HHS) and visual analogue scale (VAS) before surgery and at final follow-up. Results. There were 60 males and 53 females with a mean age at time of surgery of 71.2 years (SD 12.6). The mean HHS and VAS significantly improved at final follow-up, from 33.7 (SD 13.0) and 5.8 (SD 1.8) preoperatively to 66.4 (SD 16.8) and 2.1 (SD 1.8) postoperatively, respectively (p = 0.001 and p = 0.001). Overall, 28 patients (25%) showed non-progressive radiolucent lines at the level of proximal femur without radiological or clinical signs of loosening. One patient had a recurrence of periprosthetic joint infection after a two-stage procedure requiring re-revision surgery. One patient underwent exchange of modular components for recurrent dislocation, and another case of dislocation was treated conservatively. The survival with aseptic loosening as endpoint was 100%, while stem revision for any reason was 99.1% at up to 152 months’ follow-up. Conclusion. Alloclassic Zweymüller SL primary stem showed favourable medium-term results and survival for revision total hip arthroplasty in Paprosky type I and II defects. Cite this article: Bone Jt Open 2025;6(2):186–194

Aims. A number of methods have been described to remove a well-fixed humeral implant as part of revision shoulder arthroplasty. These include the use of cortical windows and humeral osteotomies. The router bit extraction technique uses a high-speed router bit to disrupt the bone-implant interface. The implant is then struck in a retrograde fashion with a square-tip impactor and mallet. The purpose of this study was to determine the characteristics and frequency of the different techniques needed for the removal of a well-fixed humeral stem in revision shoulder arthroplasty. Patients and Methods. Between 2010 and 2018, 288 revision shoulder arthroplasty procedures requiring removal of a well-fixed humeral component were carried out at a tertiary referral centre by a single surgeon. The patient demographics, indications for surgery, and method of extraction were collected. Results. Of the 288 revisions, 284 humeral stems (98.6%) were removed using the router bit extraction technique alone. Four humeral stems (1.39%) required an additional cortical window. Humeral osteotomy was not necessary in any procedure. Most of the humeral stems removed (78.8%) were cementless. Of the four humeral stems that required a cortical window, three involved removal of a hemiarthroplasty. Two were cemented and two were cementless. Conclusion. The router bit extraction technique removed a well-fixed humeral component in a very high proportion of patients (98.6%). This method allows surgeons to avoid more invasive approaches involving a cortical window or humeral osteotomy, and their associated complications. Cite this article: Bone Joint J 2019;101-B:1280–1284

We report on 397 consecutive revision total hip replacements in 371 patients with a mean clinical and radiological follow-up of 12.9 years (10 to 17.7). The mean age at surgery was 69 years (37 to 93). A total of 28 patients (8%) underwent further revision, including 16 (4%) femoral components. In all 223 patients (56%, 233 hips) died without further revision and 20 patients (5%, 20 hips) were lost to follow-up. Of the remaining patients, 209 (221 hips) were available for clinical assessment and 194 (205 hips) for radiological review at mean follow-up of 12.9 years (10 to 17.7). The mean Harris Hip Score improved from 58.7 (11 to 92) points to 80.7 (21 to 100) (p <  0.001) and the mean Merle d’Aubigné and Postel hip scores at final follow-up were 4.9 (2 to 6), 4.5 (2 to 6) and 4.3 (2 to 6), respectively for pain, mobility and function. Radiographs showed no lucencies around 186 (90.7%) femoral stems with stable bony ingrowth seen in 199 stems (97%). The survival of the S-ROM femoral stem at 15 years with revision for any reason as the endpoint was 90.5% (95% confidence interval (CI) 85.7 to 93.8) and with revision for aseptic loosening as the endpoint 99.3% (95% CI 97.2 to 99.8). We have shown excellent long-term survivorship and good clinical outcome of a cementless hydroxyapatite proximally-coated modular femoral stem in revision hip surgery. Cite this article: Bone Joint J 2014;96-B:730–6

Near 70% of failures of knee arthroplastys due to septic or aseptic mobilization are complicated because of massive loss of bone stock. In these cases surgeon have to perform a salvage procedure to restore legamentous balance, articular plane direction and axes of lower limb, finally to fill bone defects. Today intrinsic biomechanical stability of revision implant is entrust to sophisticated design and materials of custom made and modular implants. Endomedullary stem has to assolve specific functions: mechanical stability contrasting stress due to the boneloss, offering support for omoplastic or spongious bone innests in femoralor tibial defects. There are paucity of study in literature about dimension and morphology of endomedullary canal, probably because of variability between periostal andendostal anatomy in each patients, specially age related. This date has conditioned production of several number of revision stem size for all population. This anthropometric study verify presence of a particular regionin femoral and tibial endomidullar canal not dependent from sex, height, morphotype, important for a good press-fit of revision stem. Morphological date of midfemoral and tibial geometry was assessed in 50 subjects using Axial Computerized Tomography. Eleven (22%) were in men, thirty nine (78%) were in woman, with avarage of 73 years old (from 57 to 85). Exclusion criteria were previous operation at the same limb, deformity, pathology of bone metabolism. The level of sections were at 20, 18, 16 and 12 centimiters from articular plane for femur and at 8, 10, 13, 16 cm for tibia. Preliminar Ct scan with hight resolution program with bone alghoritm was performed. Axial view of any section was visualized at real dimension and maximal and minimal diameter of sections e were measured in millimiters. Areas of any section is different in each patient; this variability is greater near articular plane. Infact in our sample SD (Standard Deviation) of diameters of proximal femoral and distal tibialsections was lesser than SD of the other measurements. No difference of results about sex was noted. On base of these measuremts more proximal two femoral sections and two more distal tibial sections were considered to elaborate an ideal area for anchorage zone of anatomical revision stem. We subdivided all sample in five groups with homogeneous value of diameter in selected sections. For any groups tangent & #945; of an ideal trunk of cone including maximum and minimum value of diameter considered was computed, and the relative inclination angle. In our sample the greatest diameter in proximal femoral section was 20 mm and the lowest 10 mm; for tibial measuremnts the greatest value in distal tibial level was 18 mm and the lowest was 10 mm. Inclination angle was ever around 2° in all groups. Moreover we have calculated the presumable length of an ideal trunk of cone that includes the minimum and maximum value of femural and tibial diameter measured. About 5% of knee arthroplastys is destinated to an unsuccessfull. In many cases loosing of bone stock is huge and localized near articular plane. Afterward it’s important to restore biomechanical stability through endomedullary stem of revision implant. There are not many reports about morphology and anatomical study of femoral and tibial endomedullary canal. Many authors focus the attention on bone density or functional axes of the lower limb. Some authors studied remodelling process age-related about periostal ad endostal bone; cortical area undergoing thinning specially over fourthy years old. Our sample had mean of 73 years old: remodelling process is almost complete and then it is a good referenceto extrapolate real data about endomedullary morphology and width. Variability of data in all population about diameter of endomedullarycanal is lesser near femoral and tibial istmo, in particular around 18–20 cm from articular plane for femur and at 13–16 cm for tibia In our opinion short stem can’t guarantee good press-fit because of extreme variability of diameters in the population near knee. This anthropometric study confirm presence of anatomical area of the midfemural and tibial canal with common geometric characteristic in allpatient; it can be used to realize an anatomical stem that guarantees a good contact bone/prosthesis and then an optimal bone integration. On base of our results it is possibile realize few revision stem because in all groups of patients studied at 18–20 cm from knee for femur and at 13–16 cm for tibia, angle of inclination was ever 2°

Tapered fluted titanium stems are increasingly used for femoral revision arthroplasty. They are available in modular and non-modular forms. Modularity has advantages when the bone loss is severe, the proximal femur is mis shapen or the surgeon is unfamiliar with the implant, but it introduces the risk of fracture of the stem at the junction between it and the proximal body segment. For that reason, and while awaiting intermediate-term results of more recently introduced designs of this junction, non-modularity has attracted attention, at least for straightforward revision cases. . We review the risks and causes of fracture of tapered titanium modular revision stems and present an argument in favour of the more selective use of modular designs. Cite this article: Bone Joint J 2016;98-B(1 Suppl A):50–3

Introduction: Revision surgery for stem loosening and peri-implant bone loss of variable extent is a major challenge for orthopedic surgeons. Our strategy has been to use cementless straight stems of rectangular cross-section for revisions. To ascertain the value of this implant we analyzed the results at a minimum follow-up of 10 years. Material and Method: Between October 1991 and end 1998, 125 patients (134 hips) underwent revision surgery. Of these, 39 were males and 86 were females. Sixty-seven of the original implants were cemented and as many were cementless. Cementless revision stems (SLR; Plus Orthopedics, Aarau, Switzerland) size 3 to 11 (180 to 223 mm in length) were used for revisions. Patient age at the time of surgery was 37.8 to 89.3 (mean, 71.0) years. Fifty patients (53 hips) died post revision 0.0 to 13.5 (mean, 6.8) years. Their implants had been followed-up radiographically for 0.0 to 9.2 (mean, 3.6) years. At the time of revision these patients had been 48.9 to 89.3 (mean, 76.7) years old. One of them had undergone stem revision for aseptic loosening one year post surgery. Another 6 were revised 1.4 to 13.9 years post surgery, 5 for low grade infection and 1 for peri-implant fracture. Seven patients refused to present for follow-up because of advanced age and poor cooperation. Eight were contacted by telephone. These 15 patients were not re-operated. Five patients were altogether lost to follow-up, thus leaving a total of 53 hips (49 patients) for analysis at a follow-up time of at least 10 years. The follow-up time was 10.0 to 16.1 (mean, 11.6) years. For radiographic follow-ups monitor-guided a.-p. and axial radiographs were recorded. These were analyzed by Gruen zones. Results: All stems were properly aligned along the long femoral axis, except in 1 patient, who had sustained a peri-implant fracture during a fall with axial stem subsidence responding to conservative treatment. In 38 patients peri-implant bone apposition was detected in all 7 Gruen zones. This was combined with bone resorption in other zones in 2 patients. Four patients presented with osteolytic lesions. In one of them with metal-on-metal articulating surfaces, the lesion extended to several segments and will necessitate revision. All other stems were stable. None of them was at risk. Conclusion: This analysis showed that the SLR revision stem performs well for an intermediate follow-up time of at least 10 years

We describe the clinical and radiological results of 120 consecutive revision hip replacements in 107 patients, using the JRI Furlong hydroxyapatite-ceramic-coated femoral component. The mean age of the patients at operation was 71 years (36 to 92) and the mean length of follow-up 8.0 years (5.0 to 12.4). We included patients on whom previous revision hip surgery had taken place. The patients were independently reviewed and scored using the Harris hip score, the Western Ontario and McMaster Universities osteoarthritis index (WOMAC) and the Charnley modification of the Merle d’Aubigné and Postel score. Radiographs were assessed by three reviewers for the formation of new bone, osteolysis, osseointegration and radiolucent lines in each Gruen zone.

The mean Harris hip score was 85.8 (42 to 100) at the latest post-operative review. The mean WOMAC and Merle d’Aubigné and Postel scores were 34.5 and 14.8, respectively. The mean visual analogue score for pain (possible range 0 to 10) was 1.2 overall, but 0.5 specifically for mid-thigh pain. There were no revisions of the femoral component for aseptic loosening. There were four re-revisions, three for infection and one for recurrent dislocation. Radiological review of all the femoral components, including the four re-revisions showed stable bony ingrowth and no new radiolucent lines in any zone. Using revision or impending revision for aseptic loosening as an end-point, the cumulative survival of the femoral component at ten years was 100% (95% confidence interval 94 to 100). We present excellent medium- to long-term clinical, radiological and survivorship results with the fully hydroxyapatite-ceramic-coated femoral component in revision hip surgery.

We aimed to assess whether using long stem femoral components, with cemented distal fixation and proximal impaction grafting allows early patient mobilisation, reconstitution of the proximal femur and long term stability of fixation in patients with aseptic loosening and proximal femoral analysis.

Over the past ten years 239 patients have been treated with an Elite Plus cemented long stem femoral implant, 33% with concomitant proximal impaction bone grafting. Many of the patients had co-morbidities. The average age at revision was 72 years (range 48 to 91). There was a slight female predominance. Fourteen percent of hips had been previously revised. Forty-eight patients were deceased and 22 were not available for follow-up; this left a cohort of 169 patients who were available for radiological and questionnaire review at an average of 4.5 years.

According to the Paprosky grading for pre-operative bone loss 40% had moderate to severe bone loss (grade IIIb or IV). The Barrack grading was used to assess the cement mantle post-operatively with 65% showing good cementation. The Harris and O'Neill grades were used at final review to assess probability of loosening with only 8% being probably or definitely loose. The average Oxford Hip Score was 29. Mesh ± cables were required in a third of cases to allow adequate containment and pressurisation. It was generally felt that the long stem needed to be at least one third longer than the initial component. The re-revision rate was 1.2 with a 10 year survivorship analysis of 94%. The complication rate of almost 6% included periprosthetic fractures, dislocations, infection and mesh breakage.

A long stem cemented femoral implant can be useful in bypassing proximal femoral deficiency in the appropriate patient.

We have reviewed the intermediate term results of 56 out of 61 consecutive Wagner revision stems implanted without bone graft. After a mean of 5 years (range 4 to 7 years) 49 out of 56 hips were graded as excellent or good based on the Harris Hip Score. The clinical result was not related to the degree of femoral bone defect prior to revision. 49 Out of 56 hips were seen to subside, but this did not affect the hip score at final review. The mean subsidence was 4.8mm (range 0 – 19mm).Only one stem showed continued subsidence after 12 months post-operatively, and this stem achieved a stable position by 24 months. All osteotomies of the femur united with reconstitution of the femoral bone stock. There was a low incidence of complications; one stem showed catastrophic subsidence within 48 hours of surgery, requiring re-revision to a larger Wagner stem. There was one sciatic nerve palsy. 3 hips dislocated on one occasion in the early post-operative period, but were stable at latest follow-up. In conclusion, the Wagner stem can bypass major proximal femoral bony defects and achieve initial axial and rotational stability in intact diaphyseal bone. Subsequent stem subsidence does not affect clinical outcome, and proximal femoral bony reconstitution is achieved without the need for bone grafting

Short-stem total hip arthroplasty (THA) may have bone sparing properties, which could be advantageous in a younger population with high risk of future revision surgery. We used data from the AOANJRR, LROI and SAR to compare survival rates of primary THA, stems used in the first-time revision procedures as well as the overall survival of first-time revisions between a cohort of short-stem and standard-stem THA. Short-stem THAs (designed as a short stem with mainly metaphyseal fixation) between 2007 and 2021 were identified (n=16,258). A propensity score matched cohort (1:2) with standard THAs in each register was identified (n=32,515). The cohorts were merged into a research dataset. Overall survival at 12 years follow-up was calculated using Kaplan-Meier survival analyses. Stem revisions (short-stem THA n=239, standard-stem THA n=352) were identified. The type of revision stem was classified as standard (<160 mm) or long (>160 mm). The survival rate of all first-time revisions in the two groups was calculated using any type of revision as outcome. The 12 year- overall survival rate (all revisions, all causes) for primary short-stem THAs was 95.3% (CI 94.5–95.9%), which was comparable to 95.2% (CI 94.7–95.7%) for standard-stem THAs. In the short-stem THA group, a standard stem (<160 mm) was more often (59%) used in the first-time revision than in the standard-stem group (47%, p=0.004). The overall survival of the first-time revisions did not differ between cases primarily operated with a short or a standard stem. In our multi-national register study, the overall survival rate of short stems was similar to that of standard stems. In short stem revisions there was a higher likelihood of using a standard-length stem for the revision compared with first-time revisions of standard stems. This finding might indicate bone-sparing properties with short-stemmed THAs

We report the medium term results using an extensively porous coated cementless femoral stem for revision hip arthroplasty in 129 cases.

166 femoral revisions were performed using the Solution cementless stem between 1991 and 1997 in 4 hospitals within our region. 30 patients had died and 7 were lost to follow up leaving 122 patients ( 129 hips ) available for assessment.

All were independently reviewed, questioned about thigh pain, and scored using the Charnley modification of the Postel-D’Aubigne Hip Score. Post operative complications and need for further surgery were noted.

Radiographs were assessed to identify component subsidence, osteolysis and stress shielding.

At mean 5 year follow up (range 2–8 yrs), 9 stems (7%) had been revised and a further 4 stems (3%) were subsiding. Of the remaining components, 8 stems (7%) showed fibrous union and 108 stems (92%) bone ingrowth.

Mild to moderate stress shielding was common but did not seem to affect fixation.

Our findings indicate that satisfactory medium term stability can be achieved using diaphyseal fixation in the mechanically or biologically proximally deficient femur.

Failure due to subsidence occurs due to undersizing, occurs early and progresses.

Introduction. Stem revision with retention of the old cement mantle (cement-in-cement revision) in cases with an intact cement/bone interface is an appealing option. There has been an increasing use of this technique. In 2014 this cement-in- cement technique was used in 10% of all stem revisions reported to the Swedish Hip Arthroplasty Register (SHAR). We analysed the outcome of cement-in-cement stem revisions reported to the SHAR during years 2001–2014. Patients/Materials & Methods. Since 2001 1292 cement-in-cement revisions (study group), performed with a short (≤150 mm) Exeter stem (n=973) or a Lubinus stem (n=319) were reported to the SHAR. Stem revisions, using short Exeter and Lubinus stems without the use of the cement-in-cement technique (n=2893) acted as the control group in this analysis. Both groups were comparable regarding primary diagnosis. In the study group there were more females and the mean age (73 years) was 2 year older (p<0.001). The primary outcome was re-revision due to all causes (n=413). Re-revision of the stem due to all causes, infections excluded (n=212) was used as secondary outcome. Survival analysis using Kaplan-Meier was performed. Results. Survival with re-revision due to all causes at 8 years in the cement-in-cement group (85±3%) was comparable to the control group (84±2%) (p=0.73). The survival of the stem with re-revision due to aseptic loosening at 8 years did not differ between the groups (92±3% and 91±1% respectively) (p=0.52). Discussion. Cement-in-cement revisions had a re-revision rate of the same magnitude as in revisions where the cement mantle was extracted. In this later group more severe bone defects may be present. Conclusion. We believe that cement-in-cement revision with a shorter operation time and less preoperative complications could be an attractive option in cases with intact cement/bone interface

We revised 24 consecutive hips with loosening of the femoral stem using impaction allograft and a cemented stem with an unpolished proximal surface. Repeated radiostereometric examinations for up to two years showed a slow rate of subsidence with a mean of 0.32 mm (−2.0 to +0.31). Fifteen cases followed for a further year showed the same mean subsidence after three years, indicating stabilisation. A tendency to retroversion of the stems was noted between the operation and the last follow-up. Retroversion was also recorded when displacement of the stem was studied in ten of the patients after two years. Repeated determination of bone mineral density showed an initial loss after six months, followed by recovery to the postoperative level at two years. Defects in the cement mantle and malalignment of the stem were often noted on postoperative radiographs, but did not correlate with the degrees of migration or displacement. After one year, increasing frequency of trabecular remodelling or resorption of the graft was observed in the greater trochanter and distal to the tip of the stem. Cortical repair was noted distally and medially (Gruen regions 3, 5 and 6). Migration of the stems was the lowest reported to date, which we attribute to the improved grafting technique and to the hardness of the graft.

We report our experience of revision total hip replacement (THR) using the Revitan curved modular titanium fluted revision stem in patients with a full spectrum of proximal femoral defects. A total of 112 patients (116 revisions) with a mean age of 73.4 years (39 to 90) were included in the study. The mean follow-up was 7.5 years (5.3 to 9.1). A total of 12 patients (12 hips) died but their data were included in the survival analysis, and four patients (4 hips) were lost to follow-up. The clinical outcome, proximal bone regeneration and subsidence were assessed for 101 hips. The mean Harris Hip Score was 88.2 (45.8 to 100) after five years and there was an increase of the mean Barnett and Nordin-Score, a measure of the proximal bone regeneration, of 20.8 (-3.1 to 52.7). Five stems had to be revised (4.3%), three (2.9%) showed subsidence, five (4.3%) a dislocation and two of 85 aseptic revisions (2.3%) a periprosthetic infection. . At the latest follow-up, the survival with revision of the stem as the endpoint was 95.7% (95% confidence interval 91.9% to 99.4%) and with aseptic loosening as the endpoint, was 100%. Peri-prosthetic fractures were not observed. We report excellent results with respect to subsidence, the risk of fracture, and loosening after femoral revision using a modular curved revision stem with distal cone-in-cone fixation. A successful outcome depends on careful pre-operative planning and the use of a transfemoral approach when the anatomy is distorted or a fracture is imminent, or residual cement or a partially-secured existing stem cannot be removed. The shortest appropriate stem should, in our opinion, be used and secured with > 3 cm fixation at the femoral isthmus, and distal interlocking screws should be used for additional stability when this goal cannot be realised. Cite this article: Bone Joint J 2014;96-B:889–95

Femoral impaction grafting with cancellous bone and cement is an important technique in reconstituting deficient bone stock in revision hip arthroplasty. We report the medium to long term results of 75 consecutive patients using a collarless, polished, tapered femoral stem with an average age of 68 (±11.4) years and a mean follow up of 10.5 (±2.4) years (range 6.3 to 14.1 years).

The median Endoklinik pre-operative bone defect score was 3 (IQR: 2–3) with a median subsidence at 1 year of 2mm (IQR: 1–3mm). At the most recent follow-up (mean 10.5±2.4 years), the median Harris Hip Score (HHS) was 80.6 (IQR: 67.6–88.9) and median subsidence 2mm (IQR: 1–4mm). Ten-year survivorship with any further femoral operation as an endpoint was 92%. Four prostheses required further revision.

Subsidence of the Exeter stem continued, albeit at a slower rate after the first year and was related to the Endoklinik pre-operative bone loss (p=0.037). The degree of subsidence at 1 year was a strong predictor of long term subsidence (p<0.001). Neither subsidence nor bone stock were related to long term outcome (HHS). There was a correlation between previous revision surgery and a poor Harris Hip Score (p=0.028) and those who had undergone previous revision surgery for infection had a higher risk of complications (p=0.048).

The good long term results of this technique commend its use in revision hip arthroplasty for patients with poor femoral bone stock.

Femoral impaction bone allografting has been developed as a means of restoring bone stock in revision total hip replacement. We report the results of 75 consecutive patients (75 hips) with a mean age of 68 years (35 to 87) who underwent impaction grafting using the Exeter collarless, polished, tapered femoral stem between 1992 and 1998.

The mean follow-up period was 10.5 years (6.3 to 14.1). The median pre-operative bone defect score was 3 (interquartile range (IQR) 2 to 3) using the Endo-Klinik classification.

The median subsidence at one year post-operatively was 2 mm (IQR 1 to 3). At the final review the median Harris hip score was 80.6 (IQR 67.6 to 88.9) and the median subsidence 2 mm (IQR 1 to 4). Incorporation of the allograft into trabecular bone and secondary remodelling were noted radiologically at the final follow-up in 87% (393 of 452 zones) and 40% (181 of 452 zones), respectively.

Subsidence of the Exeter stem correlated with the pre-operative Endo-Klinik bone loss score (p = 0.037). The degree of subsidence at one year had a strong association with long-term subsidence (p < 0.001). There was a significant correlation between previous revision surgery and a poor Harris Hip score (p = 0.028), and those who had undergone previous revision surgery for infection had a higher risk of complications (p = 0.048). Survivorship at 10.5 years with any further femoral operation as the end-point was 92% (95% confidence interval 82 to 97).

Introduction:

Severe bone loss creates a challenge for fixation in femoral revision. The goal of the study was to assess reproducibility of fixation and clinical outcomes of femoral revision with bone loss using a modular, fluted, tapered distally fixing stem.

Periprosthetic fractures (PPF) of the femur following total hip arthroplasty represent a significant complication with a rising incidence. The commonest subtype is Vancouver B2 type, for which revision to a long uncemented tapered fluted stem is a widely accepted management. In this study we compare this procedure to the less commonly performed cement-in-cement revision. All patients undergoing surgical intervention for a Vancouver B2 femoral PPF in a cemented stem from 2008 – 2018 were identified. We collated patient age, gender, ASA score, BMI, operative time, blood transfusion requirement, change in haemoglobin (Hb) level, length of hospital stay and last Oxford Hip Score (OHS). Radiographic analysis was performed to assess time to fracture union and leg length discrepancy. Complications and survivorship of implant and patients were recorded. 43 uncemented and 29 cement-in-cement revisions were identified. There was no difference in patient demographics between groups. A significantly shorter operative time was found in the cement-in-cement group, but there was no difference in transfusion requirement, Hb change, or length of hospital stay. OHS was comparable between groups. A non-significant increase in overall complication rates was found in the revision uncemented group, with a significantly higher dislocation rate. Time of union was comparable and there were no non-unions in the cement-in-cement group. A greater degree of stem subsidence was found in the uncemented group. There was no difference in any revision surgery required in either group. Three patients in the uncemented group died in the perioperative period, compared to none in the cement-in-cement group. With appropriate patient selection, both cement-in-cement and long uncemented tapered stem revision represent appropriate treatment options for Vancouver B2 fractures

Introduction Impaction grafting in revision hip arthroplasty has now been used with a number of cemented stem designs. Follow-up has been short/intermediate with variable results due to pronounced stem subsidence and incomplete cement mantles. This study investigated the performance of a cementless, HA-coated stem used with the impaction grafting technique.

Methods We performed revision hip arthroplasty on a series of 16 stems for mechanical loosening (majority type II) in 14 patients (mean age 64 years). An uncemented Anatomic® stem was inserted into a neomedullary canal of impacted fresh frozen allograft bone. Stem migration was assessed with RSA. Graft and host cortical bone remodeling were evaluated radiographically as was the quality of the impaction grafting and amount of radiographic bone ingrowth. Bone mineral density (BMD) was assessed with DEXA at two and 10 years. Harris Hip Score was recorded for clinical assessment.

Results At six months the stems had subsided 0.78 mm (−7.78 – 0.22). Thereafter, the majority stabilized (6 months vs. 12 years: p=0.3). The graft had a homogenous distribution proximally, but to a lesser extent distally. Remodeling of graft was frequently seen at two years, especially proximally. There were no signs of graft resorption and no change in BMD in any Gruen zone between two and 10 years (P=0.15 – 0.54). About one third of patients had evidence of cortical restitution. In most cases there were no radiolucencies at all between the HA-fiber mesh and the bone. Slight cortical erosion at the stem tip was observed in nine cases but none progressed after two years. These parameters (remodeling, ingrowth and radiolucencies) changed minimally between the two and 12 years. At two years, the Harris Hip (50 to 85) and pain scores (20 to 40) had increased (p = 0.001). Thereafter the scores remained stationary. One hip dislocated during the first year. Heterotopic ossification occurred in three cases. One case underwent two stage revision at 30 months for late infection. One fracture was detected post-operatively. This stem subsided 16.2 mm at two years requiring revision. One patient died due to unrelated causes. Early migration was seen. Radiographs suggest much of the graft was substituted with living bone with no deterioration between two and 12 years.

Conclusions Our findings are sufficiently encouraging to initiate trials of uncemented stems with extended HA coatings.

In relation to the conduct of this study, one or more of the authors is in receipt of a research grant from a non-commercial source.

The early revision rate in elective Total Hip Arthroplasty (THA) three years after surgery in elderly patients over 80 years is significantly lower for cemented stems in the German Arthroplasty Register (EPRD): cemented 3,1% (3.0 – 3.2) vs. uncemented 4.2% (4.1 – 4.3; p < 0.001). However, the mortality rate in elderly patients is elevated for cemented fixation. This study presents a detailed analysis of the influence of stem type and fixation on revision and mortality rate in this patient cohort.

Elective primary THA cases for primary Coxarthrosis using uncemented cups from the EPRD data base were analysed (n₀= 37,183). Four stem type groups were compared: cementless, cementless with collar, cementless short, and cemented. Stems with at least 300 cases at risk three years after surgery were analysed individually. The reference stem was determined as the stem with the lowest revision rate and at least 1000 cases under surveillance 3 years after surgery (n₃ = 28,637).

The revision rate for cemented stems (2.5% [2.2–1.81] was lower than for uncemented (4.5% [4.2–4.9]; p<0.001) and uncemented short stems (4.2% [3.1–5.7]; p=0.002). The revision rate of uncemented collared stems (2.3% [1.5–3.6]) was similar to cemented stems (p=0.89) and lower than for uncemented stems (p=0.02). One year mortality showed no sig. differences between the groups (p>0.17): cemented 3.2% [2.9–3.6], uncemented 3.4% [3.1–3.7], uncemented short 3.5% [2.5–4.9], uncemented collar 2.0% [1.2–3.2].

“Cementless” and “cementless short” stems should not be used in patients over 80 years due to the higher revision risk. If cementing should be avoided, “cementless collared” stems seem to be a good alternative combined with a tendency for a lower one year mortality rate.